Does health insurance cover emergency room visits?

Emergency rooms don’t require an appointment and they’re equipped to treat you in life-threatening situations

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Derek SilvaSenior Editor & Personal Finance ExpertDerek is a former senior editor and personal finance expert at Policygenius, where he specialized in financial data, taxes, estate planning, and investing. Previously, he was a staff writer at SmartAsset.

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An emergency room, or ER, is the department of a hospital that deals with emergency services, and cares for patients without an appointment. You can go to an emergency room on your own or you can take emergency transportation, like an ambulance. Emergency rooms are typically designed to respond to life-threatening illnesses and injuries that require immediate attention.

Under the Affordable Care Act (Obamacare), health insurance plans are required to cover emergency services. They also cannot charge you higher copays or coinsurance for going to an out-of-network emergency room.

Key takeaways

  • An “emergency” is usually a situation that is life-threatening or could result in the loss of a limb without immediate attention

  • Obamacare requires insurers to cover emergency services at the same price whether a hospital is in or out of network

  • Even if your insurance covers it, an emergency room visit can leave you with thousands of dollars in medical bills

  • Urgent care centers can be a cheaper and faster option for situations that aren’t life-threatening

To count as an emergency, you usually need to have a life-threatening situation or you need to have an injury that could result in the loss of a limb without immediate medical attention.

Even if it’s covered, emergency room care can cost you thousands out of pocket. Going to an out-of-network hospital or an out-of-network doctor will likely increase your bill. Taking an ambulance can cost more if the insurance deems that it wasn’t necessary.

To avoid the potential cost of an emergency room, consider visiting an urgent care center for non-life-threatening situations. Not all areas have urgent care centers and you could still end up with a bill, but they usually cost less and offer faster service than emergency room visits.

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What an emergency room does

The main function of emergency rooms (or the emergency department of your local hospital) is usually to treat life-threatening illnesses and injuries. They have advanced diagnostic equipment and access to more types of medicine than your primary care doctor might. They also have more specialist physicians available, such as cardiologists.

An emergency room is also equipped to handle surgeries and often has a trauma center, which treats major injuries from things like big falls or gunshot wounds. Some hospitals also offer specialized emergency care, like a pediatric emergency department for children.

When can you go to the emergency room?

You can go to the emergency room in any situation, but it will cost significantly more if you only get treatment for minor illnesses. You don’t need an appointment, but you may have to wait longer to be seen if there are people there whose conditions are more severe.

In some cases, an emergency room is the only option if you need medical attention but the office of your primary care physician is closed.

Does insurance cover an emergency room visit?

If you need emergency care, you should go to the nearest emergency room and feel confident that your insurance will cover it. Obamacare requires all plans to cover emergency services. Insurers cannot charge you more for going to an out-of-network hospital or health care provider. They also cannot require you to get pre-authorization before getting service.

Emergency services are included in the 10 essential benefits all marketplace plans must cover.

The big caveat is that the definition of an emergency may vary slightly from one insurance plan to the next. If you go to the ER under different circumstances, you could have thousands of dollars in medical expenses.

Even if you do have an emergency situation, your insurance company may only cover your care up to the point where your health is stable. You could have to pay after that, and if you’re at an out-of-network hospital or receiving care from an out-of-network doctor it could get even more expensive.

Another key thing to remember is that “covered” doesn’t mean that there’s no cost for you. You probably still have out-of-pocket costs like copays, coinsurance, and deductibles.

How emergency room billing works

Even if your insurance covers emergency care, you could still end up with high medical bills, depending on where you go and the details of your insurance plan. A big reason for that is something called balance billing.

Each insurance company has a negotiated rate with the hospital or emergency room. This is how much the insurer will pay the hospital and its physicians for certain services they provide to you.

You are responsible for paying whatever out-of-pocket expenses your insurance plan dictates within that negotiated rate — copays, coinsurance, and your deductibles. In an emergency situation, you pay the same rates whether you go to an in-network or out-of-network hospital.

For example, let's say you receive emergency surgery from a hospital and your insurer’s negotiated rate with the hospital for that service is $8,000. If your plan requires you to pay a deductible, you’ll pay that before the insurer pays any part of the $8,000 bill. The remaining bill after you pay the deductible will be covered by coinsurance. If your plan has a $1,000 deductible and 20% coinsurance, you will pay the first $1,000, and then you’re responsible for paying 20% on the remaining $7,000. That means an additional $1,400 out of pocket.

You can then end up with an additional bill if you go to a provider that is out of network. Let’s say you see a doctor in the emergency room who is out of your network, and that doctor charges a fee of $10,000. Two things can happen:

  1. If your insurance doesn’t cover this procedure, your insurer won’t pay this fee because it’s for an out-of-network provider. The entire fee gets passed on to you.

  2. If your insurance does cover the procedure, your insurer will cover only the negotiated rate, of which you need to pay the deductible and coinsurance. But because the provider is not in-network, he or she can still charge you the cost of the procedure that exceeds the negotiated rate. You’ll have to pay this excess balance out of pocket — that’s what balance billing, or surprise billing, means.

Emergency physicians are often independent contractors. They don’t work primarily for that hospital, and so they could very well be out-of-network health care providers for you, even if the hospital is in your network.

In the end, you pay according to the negotiated rates between your insurance and the ER. You also pay any fees that your insurance won’t cover because you went to a hospital, ER, or doctor who is out of network. Other costs are also added to your bill, like the cost of an ambulance if you took one to the hospital but your insurer determines that you had other, cheaper transportation options.

Learn more about how to read your hospital bill.

Emergency rooms vs urgent care centers

Depending where you live, you may have the option to visit an urgent care facility instead of an emergency room. Urgent care centers usually don’t have the same level of equipment as emergency rooms and they likely have fewer specialist physicians on staff, so they’re best when you have more minor injuries or illnesses. This could include anything from a bad cold to a broken bone.

Urgent care centers are usually cheaper than emergency room visits — you may only have to pay a copay with your health plan — and you are likely to receive attention more quickly. However, check the details of your insurance plan first because going to an out-of-network urgent care center could still leave you with a big bill.

You may find an urgent care clinic in a medical center, which is a facility that offers a wide range of health care services.